How to complete the Evidence Workbook

Click on the Evidence Register tab

Write a statement of compliance for each action
Lodge documents for evidence in electronic folders NB ensure the surveyors have acess to these folders. You may want
to set up a specific evidence folder structure.
Type the document name into the relevant column ie organisational or program
Hyperlink the name to the actual document or complete the file path to the source document in the next column NB
hyperlinked pdf documents will only open if Adobe Reader is version 8 or above
Click on the Audit and KPI tab
Complete the organisational KPI and audit program with target values and governance reporting
Click on the Policies and Guidelines
Drop in a report from your system if possible eg PROMPT
If this is not possible just incorporate P&Gs into the appropriate evidence section
Click on the Quality Improvement tab
Drop in a report from your quality improvement database eg Riskman Q
Complete information of activities relating to relevant actions
If the list is not extensive incorporate into evidence tab
Click on the Education tab
List examples of education programs relating to the standard

Actions

Statement of compliance

Organisational Evidence Title

Source

Program Evidence Title

Governance and leadership for effective clinical handover

6.1.1 Clinical handover policies,
procedures and/or protocols are
used by the workforce and
regularly monitored
A Clinical Handover Working Group has interdisciplinary, cross campus and consumer
representation and oversees a comprehensive and integrated approach to planning,
implementation, and evaluation of safe and effective clinical handover processes.
Handover situations identified as key priorities for targeted improvements were:
Shift to shift
Transfers and discharge.
A comprehensive gap analysis and mapping exercise were undertaken to identify
handover practices across all units. This formed the basis of the education and
implementation plan for a structured handover process, using ISBAR.
A Clinical Handover Policy and Clinical Handover Guideline were developed and are
available on PROMPT. The Guideline outlines the agreed and consistent approach to
safe and effective handover across the organisation during key points of patient
transition of care.
A Transfer and Discharge Guideline has been developed to ensure safe and effective
handover of clinical information during:

Transfer of patients between the organisation's sites and to other hospitals; and

Discharge of patients to the community and community health providers.

6.1.1 Clinical handover policies,

procedures and/or protocols are
used by the workforce and
regularly monitored

6.1.2 Action is taken to maximise

the effectiveness of clinical
handover policies, procedures
and/or protocols

6.1.3 Tools and guides are

periodically reviewed

Clinical handover processes

6.2.1 The workforce has access
to documented structured
processes for clinical handover
that include:
preparing for handover,
including setting the location and
time whilst maintaining continuity

Name the folder eg 1.1 All key

evidence items are to be stored in
Only list key evidence as
the Accreditation drive and
identified in the statement of
should not be hyperlinked. This
compliance. 5-10 items per action
will be done immediately prior to
survey

Only list key items that are given

as an example. For example
variance analysis from a pathway
that is overseen by a Program.
Programs should keep their
evidence in their usual drives

Source

Comment (eg need to

run at time from source)

Name the folder

eg 1.1 All key
evidence items are
to be stored in the
Accreditation drive
and should not be
hyperlinked. This
will be done
immediately prior
to survey

if there is a major
source of verification
evidence, for example a
list of credentialed staff,
it should be listed here
as " eg Full list
available from Chief
Medical Officer.
Committees should
EXAMPLE
keep an Evidence
Register/ Inventory
( see separate form) in
the folders related to
usual business or
committee work. It
could be made
available to surveyors if
requested.

Actions
Governance
and leadership
for effective clinical handover
time whilst maintaining
continuity
of patient care
organising relevant workforce
members to participate
being aware of the clinical
context and patient needs
6.3.1 Regular evaluation and
monitoring processes for clinical
handover are in place

6.3.2 Local processes for clinical

handover are reviewed in
collaboration with clinicians,
patients and carers

6.3.3 Action is taken to increase

the effectiveness of clinical
handover

6.3.4 The actions taken and the

outcomes of local clinical
handover reviews are reported to
the executive level of governance

6.4.1 Regular reporting,

investigating and monitoring of
clinical handover incidents is in
place

6.4.2 Action is taken to reduce the

risk of adverse clinical handover
incidents

Statement of compliance

Organisational Evidence Title

Source

Program Evidence Title

Source

Comment (eg need to

run at time from source)

6.4.2 Action is taken to reduce the

risk of adverse clinical handover
incidents
Actions
Governance and leadership for effective clinical handover

Patient and carer involvement in clinical handover

6.5.1 Mechanisms to involve a
patient and, where relevant, their
carer in clinical handover are in
use

Statement of compliance

Organisational Evidence Title

Source

Program Evidence Title

Source

Comment (eg need to

run at time from source)

6.1.3

Use of structured
handover tools

the proportion of
observed nursing clinical
handovers where an
ISBAR -based tool is
used

# observed handover
episodes where ISBARstructured tool used to
handover all patients

Target Result
Yellow

Target
Result
Red

90%

>=80%

<80%

Last Result

Result

Target
Result
Green

Clinical
Handover WG

Clinical Service
Directors

Executive
(* = KPI)

Governance Reporting

Annually

Audit Frequency

Biannually

Denominator

Triannually

Numerator

Quarterly

Definition

Monthly

Indicator Title

Daily

Related standard

Previous Result

National Standards 6 Clinical Handover - Audit Program

total # of observed
handovers
P

92.00% 89.00% 100.00%

Document title
NSQHS 06. Clinical Handover
6.1 Implement system for structured clinical handover

Date due for review

6.2 Workforce has access to documented structure for handover

6.3 Regular evaluation for clinical handover processes are in place

6.4 System for investigating handover incidents in place

6.5 Mechanisms to involve patients in handover are in use

ID

Objective

Anticipated Outcome

24

To develop principles for intra hospital Improvement of patient transfer

transfer.
processes.

NSQHS 06. Clinical Handover

6.1 Implement system for structured clinical handover

6.2 Workforce has access to documented structure for handover

6.3 Regular evaluation for clinical handover processes are in place

6.4 System for investigating handover incidents in place

Intervention

Progress against Key Milestones

Status

Program

Review of statewide principles

Organisation Principles to be
developed for transfer
Transfer Form to be developed

Clinical Alert regarding principles Good progress Medical

of safe intra hospital transfer
Services
completed and communicated to
staff
Review of statewide report
Organisation principles developed
Draft transfer form created and to
be piloted in Emergency
department
Amendments made based on the
VQC format and awaiting
publication

Contact
Person
Clinical Lead

Completion
Due
31 Jan 2013

EXAMPLE

6.5 Mechanisms to involve patients in handover are in use

Education Title

Format

Clinical Handover

elearning

Target Audience
Nursing, Allied
Health,Medicine

Schedule
mandatory

EXAMPLE